33. What to Know About Monkeypox

Contagious Conversations  /  Episode 33: What to Know About Monkeypox





Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today is Dr. Jennifer McQuiston, a captain in the U.S. Public Health Service and deputy director of the Division of High Consequence Pathogens and Pathology within the Centers for Disease Control and Prevention's National Center for Emerging and Zoonotic Infectious Diseases. As a veterinarian, Dr. McQuiston specializes in outbreak investigations and research involving diseases that spread from animals to people and believes that helping people understand how to prevent disease is her most important job. Dr. McQuiston has dedicated her career to translating science into easy-to-understand disease detection and prevention strategies to keep both people and animals healthy and active. In this episode, we discussed the current monkeypox outbreak. We will explore what CDC is doing to respond and the challenges ahead of us with the next disease outbreak response. Welcome, Dr. McQuiston.

Dr. McQuiston: Thank you so much for having me.

Claire Stinson: Well, we're honored to have you join us today. So, Dr. McQuiston, you have an extensive public health background and you specialize in outbreak investigations and research involving diseases that spread from animals to people. Tell us more about your work at CDC.

Dr. McQuiston: Well, I've been at CDC for over 24 years now, and the entirety of my career has been focused on infectious diseases and really specializing in zoonotic diseases, which as you said, are those that spread from animals to people. I've really been privileged to work on a lot of different diseases from rabies to tickborne diseases, to diseases people don't even know much about called Q fever. I've worked on a lot of different emergency responses for CDC, from influenza to Zika, COVID and of course monkeypox. But not just the current monkeypox outbreak, I actually was heavily involved in the 2003 monkeypox outbreak in the United States that happened associated with imported pet animals from West Africa. So I feel like I sort of come full circle now helping to lead this current response.

Claire Stinson: Absolutely. It sounds like it. So let's talk about monkeypox. What is it and how is it transmitted?

Dr. McQuiston: Monkeypox is an Orthopoxvirus, and it's one of several different types of viruses that are in that family. Smallpox is also an Orthopoxvirus, so there are some parts of monkeypox that are somewhat similar to smallpox. It causes a very characteristic rash. It can make people pretty sick. Smallpox vaccine actually protects people from monkeypox, but it's different in that in Africa, particularly, monkeypox is something we typically think of as spread from animals. We don't even yet know what the animal reservoir for monkeypox might be, although we continue to search for it. But it's probably some kind of rodent that lives in the jungle, and when people hunt that rodent for food or it comes closer into villages, there's a risk that monkeypox could jump from animals to humans in what we call a spillover event. And then there's a chance that monkeypox could start to spread person to person in families, in maybe healthcare workers that take care of someone with monkeypox. But what's different now is that the monkeypox outbreak that we're currently experiencing around the world seems to be spreading quite differently. There's not an animal association with it; it's been spreading person to person for some period of time. And there is a strong component of this that looks like it's being sexually transmitted, and that is something new and different that we've not seen before with monkeypox.

Claire Stinson: Thank you for explaining that. So what is CDC doing to address this outbreak?

Dr. McQuiston: We first recognized the first case in the United States on May 17th, and there had been a handful of cases that had been seen in Europe and particularly the UK that we were following news reports about. But our first case happened in mid-May, and since that time we've been working really hard with state health departments with our local partners to help track cases. And one of the most important ways we do that first is we educate doctors on how to recognize and treat monkeypox so that they know who to have them come in, order a test, make sure that they're getting the right test to diagnose it. We've been working really hard to expand testing for monkeypox. So when this disease first happened with this particular outbreak here in the United States, we already had labs across the country that could do testing for monkeypox. They were associated a lot of times with our state labs, and they were called the Laboratory Response Network labs. But very quickly we worked to expand to get testing in commercial laboratories that most doctors were more familiar with. And with that, we started to be able to diagnose cases more often and a lot easier.

Another thing that we've done to help address this outbreak is we've used vaccination really from the start. So early on when a case was identified, we worked hard to identify everybody who may have come in contact with that case. It's something we call contact tracing. And anyone who had contact with a monkeypox case was offered vaccine because if you can get the vaccine started soon enough after exposure, it may help prevent that person from getting infected. And that was the way we started with a vaccination program in the United States.

But it became really clear monkeypox was circulating primarily in the sorts of social networks where gay, bisexual and other men who have sex with men were acquiring monkeypox from partners that maybe they didn't know very well, and it made contact tracing really challenging. So when it became clear that we couldn't capture all the people who needed vaccine, we switched to a different type of vaccination strategy, sort of more of an expanded post-exposure prophylaxis strategy where vaccines started to be offered to anyone who may have had the sort of contact in the last two weeks where maybe they could have been at risk for monkeypox, even if they didn't know if they were. And that's really formed the basis of our vaccination program here in the United States.

Claire Stinson: Thank you for explaining that. CDC has certainly done so much already for this outbreak. So Dr. McQuiston, here we are two and a half years into COVID-19. It's safe to say that many Americans are dealing with COVID fatigue at this time. Is CDC facing specific challenges in dealing with another disease outbreak right now?

Dr. McQuiston: It is challenging to face another infectious disease outbreak right now when COVID is still requiring so much time and attention. There's still a large response at CDC for COVID, and we just rolled out the new bivalent vaccines for this fall to try to help protect more Americans as we anticipate possibly COVID circulating in the winter. We have flu every year that we work on, and we have other outbreaks that have happened even in the interim between COVID and monkeypox. I worked on multiple Ebola outbreaks during the COVID response. And my branch also had an outbreak of a disease called melioidosis that was associated with aromatherapy sprays that were sold through big stores in the United States. And so we've been busy.

One challenge, in particular, is when staff have been deployed in an emergency response fashion for so long, it can be hard to find staff who can then come on and take on a new response. CDC is also working to stand up and resume a lot of our critical public health work that we're engaged in every day back in our home programs. And so in addition to the public fatigue, there is also public health fatigue. Monkeypox is really different from COVID, and it's something that I've worked on for many decades and the opportunity to help people to make sure that they know how to protect themselves to help bring this outbreak under control, it's worth it, even if we're tired, to have everybody come out and help with this.

Claire Stinson: Well, we appreciate your service and it's such an important goal and mission right now. Are there learnings from the COVID response that have helped with the monkeypox response?

Dr. McQuiston: I think there have been a lot of lessons learned. The importance of moving really quickly and sharing data publicly has been one of those lessons. Not all of those lessons have been fixed yet, but I think we knew to anticipate them going into monkeypox that getting data from states in a way that makes sense to assemble at a national level has some challenges when CDC doesn't really have data authorities to tell states what they have to share and how to share it. So early in this outbreak, we worked to get data use agreements, for example, with a lot of states to make sure that as they were acquiring vaccine data, they would share it with us. So we knew to start that early.

Another lesson from COVID that I think has been very helpful for us is to think early about health equity, especially when vaccine has become such an important part of our response. So we've been thinking about that from the start. And as we're identifying health equity issues start to emerge, such as maybe a higher rates of monkeypox among people who are Black or African American or those who are Hispanic or Latino, compared to the proportion of those people who are getting monkeypox vaccine is making us think critically about how we can shift those programs to get the vaccine distributed more equitably.

I think finally, learnings from the COVID response, I want to emphasize it is different, right? I mean, we're only three and a half months into the monkeypox response. We've been moving at the speed of light, but I think the public's expectations about how fast public health moves have been permanently reshaped by what happened during a multi-year COVID response. And so we really had to hit the ground running.

Claire Stinson: That's an important point. You just talked about the cases in May, we are only a few months into this monkeypox response. So yeah, thanks for pointing that out. One issue that has surfaced during this outbreak is the stigma that certain populations are facing. Can you talk about this?

Dr. McQuiston: I think the issue of stigma is something that is so important to think about when we're communicating about monkeypox. And CDC has been working to try to combat some of those misconceptions, trying to lead with science so that stigma doesn't have a place in the conversation. But of course, stigma has found a way to creep in, I think no matter our best efforts there. So it's something that we take really seriously and we work to correct when our messages are not being received in the way that we would've hoped.

We do talk about monkeypox to the general public. It's important that people be aware of it and to understand what their risks are or what their risks aren't. But I would say a lot of our more targeted messaging to the specific groups who are at highest risk for monkeypox is something that the general public may not even see. So there's a lot of messaging that's going on in a way that's meant to sort of avoid the stigma that might come from talking specifically about risk factors to a larger population. So that is purposeful. But I think the balance of getting the important information out to those who are at highest risk for monkeypox so that they can make the right decisions to protect themselves and their loved ones is really critical. And figuring out how to do that without contributing to stigma has been a very challenging part of this response.

One of the best parts of this response for me actually has been to meet people working in other parts of CDC that I normally don't have a chance to work with every day. So these are individuals at CDC who work on HIV prevention and in our sexually transmitted infection section, and they work on stigma with this particular affected population every day. And I've learned so much from them about compassion and about how to think critically about your communications. And I think that if we're making any headway and we're getting the information out right to those at risk, it's because that group has been at the helm for our communication since the start.

Claire Stinson: We'll be right back with Dr. Jennifer McQuiston.

Monkeypox is a global public health emergency. In the United States, health officials have focused their efforts on community-level outreach to stem the tide of new cases and reduce this dangerous threat. In support, the CDC Foundation activated its Emergency Response Fund, which has played an essential role in bolstering other responses such as Ebola and COVID-19. Visit cdcfoundation.org to learn how you can help us fight monkeypox and make an impact. Now, back to our conversation with Dr. McQuiston.

Let's talk about the importance of partnerships in public health. What role are partnerships playing in this response?

Dr. McQuiston: Partnerships have been really critical. We have really great partnerships with advocacy groups that work with those who are adversely impacted by monkeypox, so those in the LGBTQI+ communities. When we put on vaccine events in the large venues where vaccine has been offered of late, those are all partnerships that are formed to make those happen. We have partnerships with social media influencers who are amplifying our message. We have put out messages about monkeypox on many of the dating apps, working hand-in-hand with them to make sure that information about monkeypox is getting out. Shifting away from communications, we've had partnerships with commercial testing companies. They weren't mandated or obligated to develop monkeypox tests really quickly, but they did so when we put out the call for assistance and they worked hard to bring those tests online quickly. So as early as early July, commercial labs were already testing for monkeypox when even just a couple weeks before the only test out there were at the state labs.

We've got really strong partnerships with our state, local, tribal and jurisdictional partners. They're the ones doing the heavy lifting to track and manage cases. And maintaining a good relationship and dialogue with them about what they're seeing is really critical to help us know how to manage this at the national level. We've got international partnerships, the World Health Organization or WHO. We have meetings with them quite regularly. Notifying very quickly when we see something unusual, and sharing information back and forth is a critical way that we learn more about this outbreak.

And I've already mentioned that we've got partnerships within CDC, people that I've never worked with before. We've got our poxvirus experts working alongside our HIV and STI experts coming together to try to develop the best response we can to support those at risk for monkeypox. So it's been really wonderful to see the variety of partnerships that have helped drive this response.

Claire Stinson: That's wonderful. Thank you for sharing that. And in previous podcasts, we've talked about the importance of community partnerships. It sounds like that would be an important theme for monkeypox as well.

Dr. McQuiston: Absolutely. I think community partnerships, particularly those that work with the groups who are at risk for monkeypox. I mean, we wouldn't have a way to communicate with them without trusted partners saying: you know what? Let me help you reach this community. Let me help amplify your message. I believe in what you're doing. It has been really one of the most critical aspects of our communication campaign. And it's working. Some recent surveys have suggested that those who are at high risk for monkeypox when we talked to them in August, about 50% said that they had changed their behaviors that were helping to drive some of the transmission because they had heard about monkeypox and they had learned what they needed to do to protect themselves. So that's really good news.

Claire Stinson: That's wonderful news. That's great to hear. It sounds like they are working. So Dr. McQuiston, what do you see as our biggest challenges ahead with the next disease outbreak response?

Dr. McQuiston: I think COVID put us in a situation where maybe we were tired, maybe we were working to try to get some fixes in place so that some of the lessons learned were ready or different when the next outbreak rolled around, but I think monkeypox came in a little ahead of its time. And so some of those systems that I see as a big challenge are how can CDC build a data management system where we're collecting data from the states in a way that helps us create a cohesive national picture so that we can figure out what's happening across time and space. So that's a challenge that I see with the next disease outbreak response, and I am sure that lessons learned from monkeypox are also now going to inform that because CDC has a lot of work ahead with our data modernization initiatives.

I am hopeful that monkeypox, because we now have real-world data on vaccines and therapeutics that before this we only had maybe an approved vaccine because there had been animal studies to show that it worked in animals, but we didn't have any sense of how well it worked in humans. We're now going to have real-world data with over 500,000 people vaccinated in the United States right now to begin to learn how well this works. And I'm hopeful that with those types of information, these vaccines may become more widely available around the world and help people everywhere, including in countries where monkeypox is enzootic or occurs naturally all the time. So that's a potential bright spot that could come out of this.

Claire Stinson: Absolutely. Thank you for sharing that. And Dr. McQuiston, you have an extensive public health background and we have a lot of students that listen to this podcast. What advice would you give anyone that's interested in a career in public health?

Dr. McQuiston: I love talking to students about a possible career in public health. I have felt like this has been a career that has been very good to me. I've been able to have a really fulfilling job and do really amazing and eclectic things and travel around the world, and there are just so many different things you can do in public health. And the other advantage of it is, I think, is that you can change around, right? I started out my career working on tickborne diseases, and then now I'm working on monkeypox. I've actually worked in CDC's Division of Public Affairs for a few years, learning how to communicate about science in a way that people could understand. So you can shift and you can change, and you can grow over the course of a public health career, you're not sort of stuck in one place.

For students that are interested in this, I mean, I do think an advanced degree is important to plan. So a Masters of Public Health is a great way to get started, number one, to see if this is a career that interests you. If you want to become a CDC epidemiologist, what we typically call a disease detective, you'll probably need a doctoral level degree, so either an MD– I'm actually a veterinarian–or a DVM, and we have some folks who come in with PhDs and epidemiology or statistics. And many of us come in through a program called the Epidemic Intelligence Service or the EIS program, that's how I was trained.

But CDC is not just epidemiologists. We have people working in the laboratory, we have policy experts, we have communications experts, we have people who help us manage our budget and think strategically about how we best use the dollars that we're entrusted with. And I think that anyone who feels a call to public service and who is interested in diseases, whether they're infectious or chronic diseases, they could find a home in public health and have a really fabulous career.

Claire Stinson: Thank you so much for sharing that. That's really great advice. Dr. McQuiston, we really appreciate all of what you have laid out for us, the importance of understanding this monkeypox outbreak, the challenges, the opportunities and what CDC is doing. Thank you so much for being a part of Contagious Conversations.

Dr. McQuiston: Thank you so much for having me.

Claire Stinson: Thanks for listening to Contagious Conversations produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your colleagues and friends. Rate the show, leave a review, and tell others, it helps us get the word out. Thanks again for tuning in and join us next time for another episode of Contagious Conversations.